Inguinal hernia

Question 1

Define an inguinal hernia.

Answer 1

Protrusion of abdominal or pelvic contents through a dilated internal inguinal ring or attenuated inguinal floor into the inguinal canal, and out of the external inguinal ring, causing an easily palpable bulge.

Question 2

What is the epidemiology of an inguinal hernia?

Answer 2

· Most common hernia.
· Much more common in males.
· Incidence increases with age.

Question 3

What is the difference between a direct vs. an indirect inguinal hernia?

Answer 3

· Direct: push directly forward through the posterior wall of the inguinal canal into a defect. Rarely strangulate.

· Indirect: pass through the deep/internal inguinal ring and if large extend through the superficial/external inguinal ring, can strangulate.

Question 4

What is the pathophysiology of an inguinal hernia?

Answer 4

· The hernia becomes clinically evident when bowel or other abdominal content fills and enlarges the empty sac.
· The sac follows the spermatic cord down to the scrotum in men, or follows the round ligament to the pubic tubercle in women.
· Direct hernias are always acquired and unusual under the age of 25 - degeneration and fatty changes. Most don’t contain bowel.
· Strangulation rarely occurs with a direct hernia.
· Strangulation is more common with an indirect hernia.

Question 5

What is the prognosis after an inguinal hernia?

Answer 5

Excellent prognosis after surgical repair.

Question 6

What are the risk factors for an inguinal hernia?

Answer 6

· Male - due to larger inguinal canal which transmitted testes in development and accommodates structures of spermatic cord.
· Old age. 
· Smoking. 
· Family history. 
· Prematurity. 
· AAA
· Previous RLQ incision. 
· Chronic bronchitis. 
· Marfan/Ehlers-Danlos. 
· Chronic cough.

Question 7

What are the typical signs and symptoms of an inguinal hernia?

Answer 7

· Groin discomfort or pain with bulge.
· Groin mass.
· Abdominal discomfort/pain:
- Indirect inguinal hernias more prone to cause pain and dragging sensation in scrotum.

Question 8

If you suspected a patient had an inguinal hernia, what investigations would you request?

Answer 8

· Clinical diagnosis (often missed though due to lack of thorough abdo exam).
· USS of groin if diagnostic uncertainty.

Question 9

Suggest some differential diagnoses.

Answer 9

· Undescended testes.
· Lymphadenopathy. 
· Femoral hernia. 
· Femoral aneurysm. 
· Psoas abscess. 
· Hydrocele - swelling in the scrotum.

Question 10

What are the treatment options if a patient has an incarcerated or strangulated hernia?

Answer 10

· 1st line - surgical repair.

· Adjunct - prophylactic abx therapy.

Question 11

What are the treatment options if a patient has a small, asymptomatic hernia?

Answer 11

1st line - watchful waiting.

Question 12

What are the treatment options if a patient has a large or symptomatic uncomplicated hernia?

Answer 12

1st line - open mesh or laparoscopic repair.

Question 13

How soon after surgery can patients return to work/drive?

Answer 13

After ≤2wks if all is well.

Question 14

What surgical options are available?

Answer 14

· Mesh techniques (Lichtenstein repair) is most popular and has low recurrence rate – mesh inserted to reinforce abdominal wall.

· Laparoscopic repair is usually reserved for recurranct or bilateral hernias – TAPP (transabdominal pre-peritoneal) or TEP (totally extraperitoneal) methods.

Question 15

What complications can arise?

Answer 15

· Post-operative urinary retention. 
· Inguinal wound haematoma. 
· Wound infection . 
· Division of the vas deferens. 
· Incisional hernia. 
· Groin pain and numbness.